Page 295 - Critical Care Nursing Demystified

280 CRITICAL CARE NURSING DeMYSTIFIED

Treatment

Le Fort fractures are reduced surgically by using direct wiring or fixation
devices.

In any soft tissue injury there is always the possibility of contamination and
infection.

Many facial wounds require tetanus immunization and a cleansing
debridement to clear the area of dirt, grease, glass, and gravel.

Nursing Diagnoses for MFIs Expected Outcomes
Airway clearance, ineffective The patient will have a clear chest x-ray
The patient will have clear breath sounds
Risk for infection The patientʼs temperature will be baseline
Surgical sites will be clean, dry, and intact
Risk for aspiration The patient will have a clear chest x-ray
The patient will have clear breath sounds
The sputum will be clear
Sputum cultures will be clear of organisms Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

Nursing Interventions
Assess bony structures and soft tissues for symmetry to determine the type
of fracture.
Assess any open areas or surgical sites for signs of infection.
Monitor the patient’s breath sounds, chest x-rays, and ABGs to look for
symptoms of infection.
Keep the patient in a position of sitting up as this is the most comfortable
and prevents blood or exudate from entering the airways.
If the patient needs a nasal gastric tube, insert it orally to prevent inadvertent
intubation of the brain through the sinuses in a nasal approach.
Administer antibiotics to prevent infection from possible CSF leak.

Administer analgesics to help decrease pain.
Debride and cleanse the wound according to health care provider’s
protocol.
Instruct the patient what to do if he or she feels like vomiting.
Keep wire clippers at the bedside to remove surgically placed wires if an
airway obstruction occurs.